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We sit down with Justin Houman, a urologist specializing in the treatment of erectile dysfunction, to explore the latest advancements in inflatable penile implants. Justin discusses how these innovative devices have evolved to offer enhanced reliability, improved aesthetics, simplified surgical techniques, and customizable options. We’ll dive into the importance of patient education, the role of antimicrobial coatings in reducing infections, and the future of erectile dysfunction treatments.

Justin Houman is a urologist.

He discusses the KevinMD article, “Latest advancements in inflatable penile implants: a men’s health urologist’s perspective.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Justin Houman. He’s a urologist. Today’s KevinMD article is “Latest advancements in inflatable penile implants.” Justin, welcome to the show.

Justin Houman: Hey, thank you. Thank you very much for having me.

Kevin Pho: So you’re a urologist, and obviously you deal with penile implants. So tell me about what you do, and just to give some context before we jump into discussion, the role of penile implants.

Justin Houman: Yeah, so I am a urologist. I specialize in men’s health. So men’s, really it’s men’s sexual and reproductive health. So guys who can’t have sex and guys who can’t have babies, really focus on the medical and surgical aspects of that.

So we all know Viagra and Cialis when it comes to erectile dysfunction. It helps the majority of men, but when those stop working we talk about penile implants. And penile implants have been around for decades. Sounds like an aggressive surgery, but it’s a relatively straightforward surgery that really helps enhance men’s sexual quality of life, for a relatively simple 45-minute procedure with a three-week recovery afterwards. So it’s a great option for a lot of men who are experiencing severe erectile dysfunction.

Kevin Pho: And tell me the type of men who come to your clinic for penile implants. I’m a primary care doctor. If someone comes to me with erectile dysfunction, you’re right, I would prescribe the Viagra, Cialis, Levitra type medications, and then if they don’t work, then I will make a referral to someone like you. So tell me the type of referrals that you get, and the type of men who normally would fail the medication options.

Justin Houman: Yeah, what’s interesting to me is, when I started my practice I never realized how young men, the age range in which men come experiencing erectile dysfunction. I have guys as young as in college, 21 year olds, literally coming with erectile dysfunction, obviously not for the penile implant but more for the Viagras and the Cialises.

But when it comes to the men for the penile implants, it’s generally older men, I’d say 50 plus, who they’ve tried the medications, the medications are irregular, they’re not consistent, they help sometimes, they don’t help other times. And it really starts, as we could all relate from a male standpoint, it really starts to affect their confidence. It affects their confidence, their relationships, and it’s kind of a downward spiral once it gets into their head. So I would say men 50 plus who want a good long-term treatment option for their erectile dysfunction.

Kevin Pho: And for the men who fail medication therapies, what are some of the reasons why those medicines don’t work in some men?

Justin Houman: So it’s a couple reasons. A lot of guys ask, so if they start Cialis at a young age, their 30s or 40s, does it have any long-term impact in terms of, do they lose sensitivity to it, does it impact them, would they not feel it the same way if they had erectile dysfunction later in life? So the answer is no. Biochemically you never develop any sensitivity or resistance to these medications.

But what happens is, especially in modern lifestyle, we’re not mobile, we’re stagnant, we sit, we spend a lot of time indoors, so our hormone levels are off, we’re more likely to have diabetes, high blood pressure, high cholesterol levels. All these things really impact the amount of blood flow that goes into our penis. And over the course of decades of having these issues, having these chronic medical conditions, if you will, it really impacts your erectile function, weakens the strength of your erections. And ultimately these medications can do a lot, but they’re not going to always work for all types of men. So eventually they do stop working.

Kevin Pho: And how about those younger men? Sometimes you see men in their 20s or 30s with erectile dysfunction. What are some common causes why that would happen to them?

Justin Houman: Yeah, so that’s a little bit different. So the mechanism, the physiology of the natural erectile function works. It’s more of a psychogenic erectile dysfunction, it’s more in their head, and that happens for a number of reasons.

I think to me, pornography is a real big reason behind that these days. Pornography is hyper-stimulating, at least if you want to. There’s a lot of pornography out there that could really stimulate you in a way that reality never will get close to. So that disconnect between what pornography provides versus what reality provides, that throws guys off.

And then more importantly, the other thing is, it’s this anxiety, depression. Those, a lot of ways they manifest with sexual dysfunction. I’ll tell you, like a lot of times I feel like I’m a therapist for these young guys, because they’re coming to me, they have anxiety issues related to whether it’s a relationship, but it’s manifesting in sexual dysfunction, when in reality everything down there hormonally, they look good from a physiology standpoint, blood flow to the penis, everything looks good. But it’s just this mental aspect of, they get in their heads every time they’re having an erection and they’re unable to perform.

Kevin Pho: So we talk more about penile implants in your KevinMD article, which talks about the latest advancements in inflatable penile implants. So let’s say I refer a patient to you and you have a man in your exam room. Tell me the types of questions that you will ask them, the type of workup that you would do to determine the next steps if they fail medical treatment, and seeing whether an implant is right for them. What kind of questions do you ask them?

Justin Houman: Yeah, so it’s really shared decision-making, in the sense of, you don’t really go backwards from the penile implant, so you really want to exhaust every option up until that point.

There’s two mainstays of treatment prior to the implant. Obviously we talked about the Viagra and the Cialis. When those don’t work, we talk about intracavernosal injections. So think of it like you’re injecting liquid Viagra directly into the penis with a small needle. The majority of my patients actually do that. And I always ask him, like, have you tried that, if you have tried that and is it not working, there’s different concentrations, how much do you want to, how far do you want to go with the injections before you consider the surgery? So you want to make sure that they’ve exhausted every option up until that point.

Then really the surgery itself, there’s two main things. Number one, the risk is infection, so you want to make sure they don’t have any predisposing factors to infection, one of them being diabetes, right? If they have high hemoglobin A1cs you want to get that under control first.

And then the other one really is, you want to make sure they have good adequate hand strength. So the pump itself, the three-piece penile implant is two cylinders that go in the penis, a pump that goes in the scrotum, and a reservoir that sits in the lower abdomen. You want to make sure men have the hand strength in order to squeeze the pump so they’re able to actually use it. There’s been times where, especially in fellowship, I’ve seen men, they’re really unable to squeeze the pump, and so there’s no point in them getting the three-piece. There’s other options for them. There’s a two-piece pump, there’s a semirigid, there’s other options for those types of men. But really want to figure out which device, which implant is right for the type of men that are coming into the office.

Kevin Pho: And you mentioned before the pump or the implant, you would try the intracavernosal injections first. So tell us a little bit about that process, how often that works and how often that fails.

Justin Houman: Yeah, so the intracavernosal injections, like I said, it’s really a wonderful option. So for example, men come to you for erectile dysfunction, you give them the Viagras and the Cialises, and then when they stop working they come to me. So I’d say about 80 to 90 percent of my male patients are on the intracavernosal injections. They do wonderful on them.

There’s different concentrations, there’s different chemicals, from a single component all the way to four components of these vasogenic, vascular stimulating agents, that essentially when you inject using a small insulin needle, you inject these chemicals directly into the base of the penis. It stimulates the blood vessels in the penis to dilate. And what’s an erection? It’s more blood flow. So as those vessels dilate, more blood comes into the penis, giving you a stronger erection.

You’re really able to use these three to four times a week. We tell patients every other day. But whereas Viagra, Cialis don’t cause any long-term issues, the more you inject with these injections, you start to scar up the smooth muscles of the penis, and over time these intracavernosal injections stop working purely as a result of injecting yourself. It creates scar, the smooth muscle doesn’t dilate the way it used to, and eventually a lot of these men get implants.

Kevin Pho: And what’s that time frame before these injections stop working?

Justin Houman: Yeah, great question. I’d say anywhere from about five to 15 years, depending on who the patient is and how often they’re using it. Some patients who are using it very regularly, they burn out a little bit faster, whereas those who don’t, takes a little bit longer.

Kevin Pho: So at the point now, let’s say we’re past the injections and we’re considering a penile implant, and you mentioned shared decision making and you talked about some of the issues that men need to think about. So tell us the type of questions they should be asking themselves to see whether a penile implant is right for them.

Justin Houman: It’s a couple things. It’s obviously in terms of manual dexterity, you want to make sure they functionally could use the penis. How important is intercourse to them, and how important is it to their partner, right? It’s an important conversation to have, because as much as some of these men have been with their partners for 30, 40, 50 years, you want to make sure that from a male standpoint, you’re doing this with the intent of engaging in intercourse with your partner. Because sometimes you do the surgery and you’re like, to what end did I do this? Because my wife is postmenopausal, she’s not even interested in intercourse.

So you have to figure out how important it is for you and your partner. That’s probably the main one. And ultimately, because otherwise, like I said, the procedure itself is relatively straightforward, and the recovery is anywhere from three to four weeks and they’re good to go.

Kevin Pho: So from a practical standpoint, I’m sure a lot of people don’t actually know how penile implants actually work. So take us through a typical scenario about how a man would use it before intercourse.

Justin Houman: Yeah, so as I mentioned, the gold standard is a three-piece penile implant. So like I said, there’s two cylinders. Every man has two erectile bodies in the penis, so we put inflatable cylinders in the penis. Those are connected to a pump that sits between the testicles. Everything is contained, everything’s under the skin. So the pump sits between the testicles, and the other end of that pump is connected to a fluid-filled reservoir, filled about 90 cc of injectable saline.

So every time a patient wants to have an erection, they squeeze the pump, the pump will transfer fluid from the reservoir directly into the cylinders, giving you an erection. And that erection will stay as long as you’d like, right? Even after orgasm, even after ejaculation, that erection is still there. Whenever you’re done, there’s a release valve, you hold the button for three seconds and the fluid from the cylinders goes back into the reservoir.

Now this particular version of the device has been around for decades, tried and true. There’s a lot of new advances in terms of antimicrobial coating preventing infection and decreasing the infection rates, because that’s probably the biggest side effect associated with this surgery. Now we’re talking about the decimals of a percentage point in terms of infection for first-time patients. And there’s newer advances that we can talk about, but it’s been around for a long, long time. Medicare fully covers this surgery, most insurance has actually fully covered the surgery. A lot of patients are surprised by that, but it’s a great option for men with severe ED.

Kevin Pho: And in terms of potential long-term side effects, or any effects on the sensitivity of the penis?

Justin Houman: Yeah, great question. Zero impact on that. So it doesn’t affect your ability to orgasm. If anything it enhances the sensation of the penis, because you’re creating a stronger erection. Zero impact on orgasm, no negative impact on sensation. But yeah, so that’s why the data on these, 98 to 99 percent of men and their partners are very, very satisfied after the surgery, sexually satisfied.

Kevin Pho: Well, you mentioned that there are other options other than the three-piece, for instance if they don’t have the manual dexterity to work it. So tell us about some of the newer options that men can consider.

Justin Houman: Yeah, so if you don’t have the strength, sometimes these patients are a little bit older, they don’t have the manual dexterity to pump the three-piece device. There’s a two-piece device called an Ambicor, where whereas the three-piece requires maybe 10 to 15 pumps, this one requires maybe one or one and a half pumps, and it gives you a strong erection, but obviously not the strength of the three piece. But no one really complains about it in terms of the strength. So about one, one and a half pumps with the Ambicor. And then in order to release it, literally you just bend your penis and the fluid will go back into the back end of it, so you become flaccid.

And then the other one is called a semirigid device. A semirigid device is, think about having two semirigid or malleable rods in those erectile bodies. So you always have an erection, you’re just pointing it in different ways. And that’s more for men who really have zero manual dexterity. So if they’re unable to do anything, they’re able to literally point the erection whichever way they want, but they’re always at baseline, they have a semirigid erection.

Kevin Pho: And then after these implants are placed, is there any maintenance? Do they wear out? Do they have to be replaced in the future?

Justin Houman: Yeah, usually I tell patients these devices last anywhere from 10 to 15 years. A lot of times it’s longer. Again, it all depends. Some guys, younger guys, they engage in aggressive intercourse on a very frequent basis. I’ve had guys within six months they’ve worn out the device, if that’s the case, but that’s incredibly rare. Like I said, most of the time it’s 10 to 15 years.

If that’s the case, we go in there, we remove the implant and we place a new one. So there’s a lot of times where patients are coming in with implants, we take them in for a removal and replacement, and a lot of the times the replacement is a lot longer, or at least a couple centimeters longer. So they’re getting a little bit more length on the device and the penis, so they’re content and they’re quite happy with that.

Kevin Pho: Now, as I said earlier, even as a physician myself, I didn’t know that much about penile implants, so this conversation to me is certainly very educational. So tell us about some of the misconceptions or misperceptions about penile implants that you’re seeing from other physicians and the public that you’d like to clear up.

Justin Houman: Yeah, so a couple things. Number one, a lot of people think it’s a very drastic, massive surgery that takes a long time and it’s a long recovery. It’s not. Like I said, the procedure itself takes about 45 minutes, it’s an outpatient procedure. Say 90 percent of men within three to four weeks they’re able to start engaging in intercourse.

Number two, it’s covered by insurance, as I said. So a lot of guys think that this is an expensive cosmetic cash procedure. It’s not, it’s all covered by insurance. So in terms of that, men don’t have to necessarily worry.

And then the third one, the most important one I would say, is guys think that people know about this. They really don’t. They really don’t. It’s very hidden, really. It’s just the mechanism, when someone is pumping it, that’s the only time someone’s able to tell. But otherwise, when you look at the penis itself, you look at the scrotum, everything is so well hidden within the skin, within the anatomy, that no one ever is able to see this device or see the fact that you have an implant.

Kevin Pho: And most urologists comfortable with the procedure? You don’t have to go to an academic medical center? Most community urologists, would they be comfortable with a variety of penile implant options?

Justin Houman: You know, I would say yeah, probably like 10, 15 years ago, yes. As you know, medicine is getting more and more sub specialized. Even urology is a tiny field, and even within our field there’s a whole field of prosthetic urology. If you’re in a big city, obviously with any surgery you want to go to somebody who does these more and more often, more common. I would say a lot of urologists probably are comfortable with this, but as the decades go on, as the years go on, less, they’re referring these patients out to men’s health specialists, prosthetic urologists like myself.

Kevin Pho: And what do we have to look forward to on the horizon when it comes to penile implants?

Justin Houman: Yeah, so right now it’s a pump, right? It’s a squeezing mechanical device. Probably sometime in the next five years one of the companies, Boston Scientific, is coming out with a Bluetooth activated version of it. So there’s no more of a pump itself with your hand. It’s going to be controlled by a Bluetooth device, your phone, and really your phone’s able to control the strength of your erection, and you’re able to really activate it just from a Bluetooth device.

Kevin Pho: We’re talking to Justin Houman. He’s a urologist. Today’s KevinMD article is “Latest advancements in inflatable penile implants.” Justin, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Justin Houman: Yeah, I would say the main thing I would try to tell men, or patients in general, is if you are experiencing any form of erectile dysfunction, the earlier you address it, the better off you will be. There’s so many treatments out there, whether it’s the Viagras, the Cialises, the Levitras, the injections. There’s newer things in terms of shock wave therapy, Botox, all these different things that can enhance the strength of your erections. But the key thing is, the earlier you address it, the better off you will be long term.

Kevin Pho: Justin, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Justin Houman: Thank you, Kevin.